Acute liver failure: avoidance of deleterious cofactors and early specific medical therapy for the liver are better than late intensive care for the brain

Acute liver failure (ALF) is a complex syndrome reflecting a rapidly progressing, life-threatening but potentially reversible, deterioration of liver function in patients recently free of any overt chronic liver disease. Since the early 1990s, a changing epidemiology of ALF has emerged. In Western countries, the incidence of viral ALF decreased [1] whereas that of drug-induced, especially acetaminophen-induced, ALF increased [1,2]. In Asian countries, although widespread use of vaccination against hepatitis B virus (HBV) was associated with a highly significant decrease in HBV-induced ALF in children [3], ‘flares’ in adults with chronic HBV infection [4] and acute hepatitis E, especially in India [5], are the main causes of ALF. According to the cause, the overall mortality rate ranges from 40 to 100% [1] and, thus, prevention of ALF [2,3,6], so often an iatrogenic complication [1,2], should become a key preoccupation of the medical community.